Howard J. Luks, MD
[pic] KNEE
Division of Sports Medicine
Howard Luks, M.D.
Chief
Patient Intake Form
Name _____________________________________________________ Date _____________________
Occupation ________________________________________________ Age _____________________
1) Who sent you to see us? Name _____________________________________________________
Address _________________________________________________ Phone ___________________
2) Who is your Internist or Primary Care Physician?
Full Name _______________________________________________ Phone ___________________
Address ____________________________________________________________________________
City, State, Zip ______________________________________________________________________
3) Chief Complaint/Current Illness:
a) Is your problem in the: Right Knee Left Knee
b) What is your chief complaint? ____________________________________________________
_________________________________________________________________________________
c) How long have you had this problem? ____________________________________________
d) Is your problem getting: Worse Better Staying the same
e) Was this a result of an injury? Yes No
If yes, please describe how it happened: ________________________________________
_________________________________________________________________________________
If yes, is this a worker’s compensation injury? Yes No (if no, advance to question #5)
4) Work-Related Injury:
a) Job title: ________________________________________________________________________
b) How long have you worked for this employer? ____________________________________
c) Date of injury: ___________________________
d) Are you: off work modified duty full duty
e) If you are not working full duty, what date did you last do so: _____________________
5) If PAIN is one of your complaints, please complete the following questions. If not, advance to Question #6.
Is your pain located in the:
Front Back Inside surface of knee Outside surface of knee œ Behind kneecap
b) Rate the average intensity of your pain/discomfort. (0=no pain, 10=severe pain)
0 1 2 3 4 5 6 7 8 9 10
c) Describe your Pain: Intermittent Constant
Dull Sharp Throbbing
Tight Burning Tingling
6) Timing
1) Is your pain worse at any particular time of the day? Morning Evening Night
2) Does your knee allow you to sleep comfortably? Yes No
7) Activity-Related Symptoms:
1) Is your knee comfortable at rest? ÿYes ÿNo
2) Can you walk without using supports (brace, crutches, cane, etc.)? ÿYes ÿNo
3) Can you walk without a limp? ÿYes ÿNo
4) Can you walk without your knee locking or catching? ÿYes ÿNo
5) Can you walk up one flight of stairs? ÿYes ÿNo
6) Can you walk up five flights of stairs? ÿYes ÿNo
7) Can you run the length of one block? ÿYes ÿNo
8) Can you run one mile? ÿYes ÿNo
9) Does your knee allow you to pivot, change directions, or jump
without “giving way”? ÿYes ÿNo
10) Does your knee allow you to perform your normal activities of daily living
(other than work or sport)? ÿYes ÿNo
11) Does your knee allow you to participate in sports? ÿYes ÿNo
12) Can you participate in sports at the level of competition you desire? ÿYes ÿNo
13) Does your knee allow you to work full-time at your job? ÿYes ÿNo
8) Do you ever have any of these additional symptoms?
YES NO If yes, describe
Stiffness ______________________________________________________
Numbness ______________________________________________________
Swelling ______________________________________________________
Instability ______________________________________________________
Weakness ______________________________________________________
Painful ______________________________________________________
Roughness ______________________________________________________
Other ______________________________________________________
9) Have you tried any of the below? Relief of Symptoms?
YES NO
Medication Type: _________________________________________________
Physical If yes, how long did you attend? _______________________
Therapy When was your last session? ___________________________
Injections If yes, where were they? _______________________________
Other Describe: _____________________________________________
10) Please list all medications you currently use with dosage and frequency: ____________________________________________________________________________________
____________________________________________________________________________________
11) Do you have any allergies? ÿYes ÿNo If yes, please list __________________________
____________________________________________________________________________________
12) Are you currently or have you ever had problems with the following:
YES NO Describe all “YES” responses
Heart Problem _______________________________________________
Breathing, Lungs ÿ _______________________________________________
High Blood Pressure _______________________________________________
Cancer _______________________________________________
Diabetes _______________________________________________
Arthritis _______________________________________________
Hepatitis, Aids, TB _______________________________________________
Liver problems _______________________________________________
Polio _______________________________________________
Epilepsy or seizures _______________________________________________
Bowls or colon _______________________________________________
Bladder problem _______________________________________________
Kidney problem _______________________________________________
Balance problem _______________________________________________
Numbness or tingling _______________________________________________
Blackout or fainting _______________________________________________
13) Please list all past surgeries and hospitalization:
Surgery/hospitalization Date Physician
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
14) Have you ever had problems with general anesthesia? YES NO
15) Do you drink alcohol? YES NO If yes, how much per week? __________________
16) Do you smoke? YES NO If yes, how much per week? ________________________
How long have you smoked? ____________________
17) Marital Status: Single Married Divorced/Separated Widowed
18) Do you:
YES NO
Have children How many _____________________________________
Live alone If no, with whom ________________________________
Use a special diet Describe _______________________________________
Use recreational drugs Describe _______________________________________
Exercise regularly How often _____________________________________
19) Sports/Hobbies: ____________________________________________________________________
20) Family History
Member Alive Deceased Age Health Status Cause of Death
Father _______ ___________ ______ _______________ ________________________
Mother _______ ___________ ______ _______________ ________________________
Sibling _______ ___________ ______ _______________ ________________________
Sibling _______ ___________ ______ _______________ ________________________
Sibling _______ ___________ ______ _______________ ________________________
21) How tall are you? _________________ How much do you weigh? __________________
Patient Signature______________________________________________ Date ________________
Thank you for taking the time to complete this information!
Reviewed by: _______________________________ Date: ________________
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